Provider Demographics
NPI:1942502596
Name:RIVERO, CARLOS ANTONIO (DMD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANTONIO
Last Name:RIVERO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 AUGUST ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1204
Mailing Address - Country:US
Mailing Address - Phone:407-923-7433
Mailing Address - Fax:
Practice Address - Street 1:5625 RUFFIN RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-6392
Practice Address - Country:US
Practice Address - Phone:858-569-9651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-01
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19106122300000X
CA104466122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003965000Medicaid